New Customer

Business Name *

Federal EIN

Driver License # (if EIN not available)

Address *

City *

State *

Zip Code *

Years of Ownership

Phone *

Email *

Fax

Estimated Weekly Purchases

Do you have a dock?

Yes
No

Preferred Delivery Method *

I will pickup at Derstine's
I am requesting deliveries*

*There is a $500 and 10 case minimum for deliveries. We cannot deliver to private residences.

Have a Sales Rep Contact Me *

Yes
No

Primary Owner/Officer Name

Primary Owner/Officer Address

Primary Owner/Officer Phone

Primary Owner/Officer Cell

Secondary Owner/Officer Name

Secondary Owner/Officer Address

Secondary Owner/Officer Phone

Secondary Owner/Officer Cell

Payment Method Requested

Cash
Check (pending approval)

*All Invoices are Payable upon Receipt*

Accounts Payable Contact

Accounts Payable Phone

Address where bills will be paid from

Bank Name

Bank Address

Bank Contact Name

Bank Phone

First Vendor Name

First Vendor Address

First Vendor Contact Name

First Vendor Phone

Second Vendor Name

Second Vendor Address

Second Vendor Contact Name

Second Vendor Phone

Third Vendor Name

Third Vendor Address

Third Vendor Contact Name

Third Vendor Phone

Vendor Comments

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